110048_SourceDisclosureCertificateV5.pdf

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Contract RFP/NJCOOP NJ|27-GNSV1-144759
Contract number
27-GNSV1-144759
Issued by
New Jersey

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This is a Source Disclosure Form issued by the State of New Jersey, Division of Purchase and Property, Department of the Treasury, in accordance with N.J.S.A. 52:34-13.2. The form is required from bidders and offerors responding to state solicitations and must be completed by contractors and all associated subcontractors as a condition of proposal acceptance.

The form requires contractors to disclose all performance locations by country where services will be provided and to justify any services that cannot be performed within the United States. Contractors must list every location where work will occur, provide descriptions of services, and explain specific reasons if services must be performed outside the United States. The Director of the Division of Purchase and Property will review any such justifications, and if deemed sufficient, may seek approval from the State Treasurer. Contractors are bound by a continuing obligation to report any changes to disclosed information throughout the contract term. Failure to comply—including shifting declared U.S.-based services to overseas sources without written Director approval—constitutes material breach of contract and grounds for termination for cause. The certification must be signed under oath by an authorized representative, with acknowledgment that false statements constitute criminal offense and will render any resulting contracts void and unenforceable.

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STATE OF NEW JERSEY—DIVISION OF PURCHASE AND PROPERTY

SOURCE DISCLOSURE FORM

Solicitation Number: _______________________ Bidder/Offeror: ______________________________________

The Contractor submits this Certification in response to the solicitation issued by the Division of Purchase and Property, Department of the Treasury, State of New Jersey ("Division"), in accordance with the requirements of N.J.S.A. 52:34-13.2.

Instructions:

List every location where services will be performed by the Contractor and all Subcontractors.

If any of the services cannot be performed within the United States, the Contractor shall state, with specificity, the reasons why the services cannot be performed in the United States.

The Contractor shall provide justification that the services cannot be performed in the United States by a contractor. The Director will review this justification and if deemed sufficient, the Director may seek the Treasurer’s approval.

Any changes to the information set forth in this Certification during the term of any contract awarded under the referenced solicitation or extension thereof will be immediately reported by the Vendor to the Director, Division of Purchase and Property (the "Director").

I understand that, after award of a contract to the Contractor, it is determined that the Contractor has shifted services declared above to be provided within the United States to sources outside the United States, prior to a written determination by the Director that circumstances require the shift of services or that the failure to shift the services would result in economic hardship to the State of New Jersey, the Contractor shall be deemed in breach of contract, which contract will be subject to termination for cause pursuant to the State of New Jersey Standard Terms and Conditions.

I further understand that this Certification is submitted on behalf of the Contractor in order to induce the Division to accept a proposal, with knowledge that the Division is relying upon the truth of the statements contained herein.

Certification: I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder; that the State of New Jersey is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with the State to notify the State in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the State, permitting the State to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print): ___________________________________________ Signature: __________________________________________________

Title: ______________________________________________________ Date: ______________________________________________________

Contractor/ Subcontractor Name

Performance Location by Country

Description of Services Reason Services Cannot Be Performed in U.S.

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Stvoreni PDF dokumenti mogu se otvoriti Acrobat i Adobe Reader 5.0 i kasnijim verzijama.)

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Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.)

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Solicitation Number:
BidderOfferor:
Contractor Subcontractor NameRow1:
Performance Location by CountryRow1:
Description of ServicesRow1:
Reason Services Cannot Be Performed in USRow1:
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Performance Location by CountryRow2:
Description of ServicesRow2:
Reason Services Cannot Be Performed in USRow2:
Contractor Subcontractor NameRow3:
Performance Location by CountryRow3:
Description of ServicesRow3:
Reason Services Cannot Be Performed in USRow3:
Contractor Subcontractor NameRow4:
Performance Location by CountryRow4:
Description of ServicesRow4:
Reason Services Cannot Be Performed in USRow4:
Full Name Print:
Title:
Date:

File details come from the government source that posted it. Updated .